Get PUMPed!
Milk Donor Application
Thank you for your willingness to donate milk.  Please answer all questions completely and honestly. 

General Information

Baby's gender *
 +
Is the baby fed breast milk: *
Are you donating milk collected prior to today? *
If yes, did you, the baby, or members of your household have ANY illness during the time you collected the milk?  *
 
Did you take any medication or herbs during this time? *
 
Has the breast pump you are using ever been used by anyone else? *
Do you plan to be an ongoing donor? *
What kind of freezer do you have? *
 
How did you hear about us? *
 
If you met us at an event, which event was it?
 

Mother's Medical Health History

Please explain any "yes" answer.  A "yes" answer will not necessarily exclude you from donating milk. *
 NoYes (please explain)
Have you ever had yellow jaundice, liver problems or disease, viral hepatitis, or a positive test for hepatitis?
In the last 12 months, have you been exposed to hepatitis A, and/or received a gamma globulin shot?
In the past 12 months have you had close contact with a person with yellow jaundice or viral hepatitis, or have you been given hepatitis B immune globulin (HBIG)?
Have you had exposure to HIV in the past year?
In the past 12 months, have you had ears or other body parts pierced, acupuncture, tattoos or permanent makeup applied with a needle, accidental hypodermic needle stick, or contact with someone else’s blood?
Have you ever had tuberculosis, exposure to TB, or positive TB test/chest x-ray?
Have you ever used bovine insulin for any reason (sometimes used to treat insulin dependent diabetes)?
Have you ever had sexually transmitted disease (syphilis, gonorrhea, chlamydia), and/or been treated for a sexually transmitted disease in the last 12 months?
Have you ever had genital or oral herpes?
Have you ever had cold sores? If yes, how often?
Have you ever had skin disease or skin lesions?
In the last 4 weeks, have you had Rubella and/or Rubella or Polio vaccinations or any inoculations or shots, or a rabies shot in the past year?
Have you received blood or blood products, or had an organ or tissue transplant in the past 12 months?
Did you have a blood transfusion given to your baby while you were pregnant?
Do you have a history of cancer or lump and/or a chronic health condition?
Have you had a serious illness in the past year?
Have you ever injected yourself with drugs or been intimate with someone who has injected drugs?
Have you ever been intimate with someone who is at risk for HIV, including anyone with hemophilia, HIV, drug users, or prostitutes?
Have you ever been told not to donate blood or milk?
Have you ever received human pituitary growth hormone, or a dura mater (brain covering) graft?
Have you or any of your blood relatives ever had Creutzfeldt-Jakob disease, or have you ever been told that your family is at an increased risk for Creutzfeldt-Jakob disease?
Do you have a history of yeast infections (systemic, vaginal, oral)?
In the past 12 months have you been under a doctor's care or had a major illness or surgery?
Did you spend 3 or more months total in the United Kingdom between 1980-1996?
Have you spent 5 years or more total in France or Europe between 1980 to present?
Please explain any "yes" answer.  A "yes" answer will not necessarily exclude you from donating milk. *
 NoYes (please explain)
Have you spent 6 months or more total on a military base in Europe between 1980 - 1990?
If you traveled to the United Kingdom, did you receive a blood transfusion or any other medical treatment with a product made from blood?
In the past 28 days have you been ill with SARS or suspected SARS? Or in the past 14 days, have you cared for, lived with, or had contact with body fluids of a SARS patient?

Baby's Medical Health History

Please explain any "yes" answer.  A "yes" answer will not necessarily exclude you from donating milk. *
 NoYes (please explain)
Was your baby jaundiced? If yes, how long did it last?
Has your baby ever had a yeast infection (i.e., thrush or diaper rash)?
Has your baby been exposed to any communicable diseases, such as chicken pox, mumps, etc.? If yes, include date of exposure.
Does your baby have repeated infections, such as colds, ear infections, diaper rash, or skin infections?
Is your baby gaining weight and growing well?
Does your baby consume anything other than your breast milk (i.e., not exclusively breastfed)? If not exclusively breastfed, check 'Yes' and explain:

Mother's Health History

Please explain any "yes" answer.  A "yes" answer will not necessarily exclude you from donating milk. *
 NoYes (please explain)
Are you taking any type of medication, prescription or over-the-counter, such as vitamins, birth control pills, herbals, laxatives, or allergy medications? If yes, please specify:
Have you taken Soritane and/or Tegison in the last 3 years?
Have you taken Proscar or Accutane in the last month, or have you taken dutasteride (Avodart) in the last 6 months?
Please list any medications/herbals taken in the week prior to pumping milk to be donated:
Do you smoke, use tobacco, or wear a nicotine patch (or use other NRT)?
Have you ever used so-called "recreational drugs" such as marijuana, cocaine, LSD, Dexedrine?
If yes, what drugs and when did you take them?
If yes, were the drugs taken by mouth, nose, smoked, or injected?
If yes, when was the last date of use (approximately)?
Are you using any of the above at present?
Do you ever consume alcohol? If yes, please describe your present daily alcohol use:
Do you ever consume caffeine? If yes, please describe your present daily intake of caffeinated beverages (e.g., sodas, coffee, caffeinated tea):
In the past 14 days have you traveled to, traveled through, or resided in areas affected by SARS (Mainland China and Hong Kong; People's Republic of China; Singapore; Taiwan; Toronto, Canada; or Hanoi, Vietnam?
In the week (7 days prior) to pumping any of the milk you are donating, have you had a fever with headache?

Mother's Obstetric and Lactation History

Please explain any "yes" answer. A "yes" answer will not necessarily exclude you from donating milk. *
 NoYes (please explain)
During this pregnancy, delivery and post-delivery period, did you have any complications, including infection, excessive bleeding or high blood pressure?
Have you breastfed before?
Have you expressed and stored milk before?
Have you ever had a breast infection? (If yes, please give dates.)
Are you on any special diet? e.g., low salt, low dairy products, vegetarian, diabetic, weight loss, etc.?

Signature & Review

Have you read the information sheet about HIV? *
 
Do you agree to have your blood tested for HIV 1 & 2, HTLV 1 & 2, Hepatitis B & C, and Syphilis? *
 
As part of our screening process, we require a medical clearance from your child's physician. Do you agree to have a medical release form signed by your child's primary physician? *
 
Have you read and understood all of the donor information presented to you, and have all your questions been answered? *
 
If you are accepted as a donor, would you allow us to use your baby's name and/or picture for promotional materials? *

I hereby certify to the best of my knowledge I understand and have answered all questions truthfully.  I have reviewed and understand the information provided to me regarding the spread of AIDS.  I do not consider myself to be a person at risk for spreading the AIDS virus or any other diseases.

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